Data Quality: UBO & The Revenue Cycle

1. Data Quality:UBO & The Revenue Cycle TMA Uniform Business Office (UBO) Deputy Program Manager

2. Outline • Uniform Business Office (UBO) Organization • UBO Cost Recovery Programs • MHS Billing Systems • MTF Revenue Cycle • Data Quality and How it Affects Each Phase of the Revenue Cycle • UBO Success Factors • Resources

3. UBO Organization Chart Dr. S. Ward Casscells ASD (Health Affairs) Director, TMA Secretary of the Army, Navy, Air Force Command – Control - Execution Policy & Guidance Army, Navy, Air Force Chief of Staff MG Elder Granger Deputy Director, TMA Army, Navy Air Force Surgeons General Mr. Alan Middleton CFO, TMA Mr. David Fisher Director, Management Control & Financial Studies Division Army MEDCOM BUMED AFMS UBO Advisory Work Group TMA UBO Program Manager Service UBO ProgramManagers (Army, Navy, Air Force) Intermediate Commands HSO/MAJCOM (Army, Navy, Air Force) Service IM/IT, legal reps & subject matter experts (SME) TMA/IRD, Unified Biostatistical Utility (UBU), Defense Health Information Management System (DHIMS), Defense Health Services Systems (DHSS), MEPRS Management Improvement Group (MMIG) MTF UBO

4. UBO Cost Recovery Programs Third Party Collections Program (TPCP) Medical Services Account (MSA) Medical Affirmative Claims (MAC)

5. Who Gets Billed Under Which Cost Recovery Program? • Third Party Collections Program • Bill insurers for care provided to eligible DoD beneficiaries (excluding Active Duty) with other health insurance (excluding Medicare & TRICARE) • Medical Services Account • Includes billing for care provided to eligible patients from Veterans Affairs/Coast Guard /NOAA/ PHS/Civilian Emergencies/Foreign Military & their Family Members • Medical Affirmative Claims • Bill for care provided to eligible DoD beneficiaries injured by third parties

6. Collections by UBO Cost Recovery Program • Third Party Collections Program (TPCP) • $159.8M (FY 2007) • Medical Services Account (MSA) • $120.1M (FY 2006) • Medical Affirmative Claims (MAC) • $16.8M (FY 2006) • ALL funds collected are retained by your MTF • TPC funds are in addition to your O&M budget

7. Direct Care TPCPFY03 – FY07- Billed & Collected ($ Millions) *NOTE: Collected includes dollars for healthcare services provided in previous FYs and may exceed current FY billings. Data source: MTF DD Form 2570 as reported to the TMA UBO Metrics Reporting System

8. Direct Care TPCP2ndQtr - Billed & Collected ($ Millions) *NOTE: Data source: MTF DD 2570 as reported to the TMA UBO Metrics Reporting System

9. MHS Billing Systems • Third Party Outpatient Collection System • Government developed system for billing outpatient TPCP (includes outpatient visits, lab/rad/pharmacy prescriptions) • CHCS Medical Services Account (MSA) Module • Government developed module used for billing TPCP inpatient claims (both institutional & professional charges) & MSA • Relationship to other systems • Provider Specialty Codes • Collection of other health insurance (OHI) information in CHCS • Centralized OHI Repository on DEERS

10. Legend Database Subsystem Data Documents Existing MHS Systems MDR M-2 DEERS TPCP OP Claims MAC Claims TPOCS ADM CHCS I PDTS WAM MSA Claims TPCP Inpatient Claims EAS IV Financial Personnel Workload

11. Status of Future MHS Billing System • Patient Accounting System (PAS) Charge Master Based Billing (CMBB) was planned to replace TPOCS and CHCS MSA Module for TPC, MSA & MAC billing • A $42.0M contract was awarded in September 2006 • Selected GE Centricity Flowcast 3.0 COTS with Unisys as the system integrator • Numerous problems were encountered during systems integration • Services voted in June 2007 to not to support FY08 funding and cancel CMBB due to functional shortcomings • Capabilities Based Assessment (CBA) underway to determine future course of action

12. Data Quality Characteristics • Accurate • Complete • Concise • Cost-effective • Relevant / Timely / Up-To-Date • Presentation • Consistent

13. MTF Revenue Cycle Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Patient Registration Provider Encounter Data Patient Registration Coding Billing Accounting INFORMATION SYSTEMS O&M Collections Cash Flow $$

14. GAO Report Findings • Results from a February 2004 GAO report identified breakdowns in each phase of the revenue cycle and the resulting adverse effects on collections Breakdowns reduce DOD’s Third Party Collections $ $ $ $ $ Medical documentation Billing Accounts Receivable Patient intake Coding • Some billable care is not identified due to coding or systems problems • Staff issues • Failure to collect & maintain insurance • information • Missing medical records • Poor medical record documentation • Inadequatefollow-up • Legal issues • Incomplete • Inaccurate Process Breakdowns Source: GAO-04-322R

15. Patient Registration • PATCAT Entry • Collection & • Validation of OHI • DQMC Assessable • Unit Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Patient Registration Patient Registration ProviderEncounter Data Coding Billing Accounting INFORMATIONSYSTEMS

16. Importance of Accurate PATCAT Entry • Patient Category (PAT) determines the reimbursable rate (if any) for healthcare • Over 300 PATCATs to select from • Challenge of Patients with Multiple PATCATs • Spouse of AD Member who is a Reservist and employed as a Federal Employee • Whose responsible for training/accuracy?

17. Training for Selecting the Correct PATCAT • Selecting correct PATCATs was added as a recurring training session at the annual UBO/UBU Conference beginning in 2005 • A TRICARE University On-line PATCAT course was developed and available for enrollees April 2007 to May 2008 • 179 people successfully completed the course • PATCAT course now available via the TMA UBO website

18. Medical Affirmative Claims (MAC) • Are all patient injuries being identified for JAG review as possible MAC cases? • Active Duty Included • Is anyone training your intake personnel to identify potential MAC claims? • If no one is responsible then it’s not getting done • How much is your MTF losing in unidentified MAC cases?

19. Other Health Insurance (OHI) Information • Use DD Form 2569 to capture OHI information about your patients • All Non-Active Duty Patients required to complete it every 12 months or if data changes • OHI needs to be entered into CHCS or it “doesn’t exist” for billing purposes • Direct correlation between presence of a current DD Form 2569 in patient record and rate of TPC billing • Reported monthly in Commander’s DQ Report

20. Provider Encounter Data • Medical Record • Availability • Documentation Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Provider Encounter Data Patient Registration Patient Registration Coding Billing Accounting INFORMATIONSYSTEMS

21. CHCS Provider Specialty Codes (PSC) • Set of codes unique to CHCS • Current business rules preclude TPOCS from receiving ADM encounters with blank PSCs or PSCs > 900 • (exception of 901 – Physician Assistant) • 702 (Clinical Psychologist) versus 954 (Psychology) • Site visit to large medical center found 20% of PSCs fields were blank • Billable ADM encounter never reach TPOCS

22. Correcting the CHCS Provider Specialty Codes (PSC) • Get your site’s most current CHCS Provider Profile and review the PSC fields for accuracy • No blank fields • Billable providers have PSC under 900 (plus 901 – Physician Assistant) • Determine whose responsible for maintaining the PSC fields and TRAIN THEM!!! • Periodically review the PSC fields to make sure the problem really has been permanently fixed

23. National Provider Identifier (NPI) Type 1 • Every provider who can bill for healthcare services is required to have one • 23 May 2007 was the deadline for MHS providers to obtain their own unique NPI Type 1 • Active Duty Statistics as of 22 May 2008 • Actual/Required (% Achieved) • Army – 14,053/11,697 (120%) • Navy – 9.288/8,864 (105%) • Air Force – 8,220/7,850 (105%) • Are all of your providers NPI Type 1s in CHCS? • No NPI = No Payment from Insurance Companies

24. Coding • HCPCS/CPT-4 • Modifiers, ICD-9-CM • Units of Service Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Patient Registration Patient Registration Provider Encounter Data Coding Billing Accounting INFORMATION SYSTEMS

25. Billing • Insurance • Verification • Claim Form Data & • Line Item Billing Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Patient Registration Patient Registration Provider Encounter Data Coding Billing Accounting INFORMATION SYSTEMS

26. Accounting • Account Follow-Up • Payment Posting • Denial Management Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Provider Encounter Data Patient Registration Patient Registration Coding Billing Accounting INFORMATION SYSTEMS

27. UBO Success Factors • What are the Focus Points? • MTF Revenue Cycle • Team Effort (not the just the UBO’s challenge) • Staff Education & Training • Electronic Interfaces • Leadership Involvement • Stress the need to complete the OHI forms (DD Form 2569s) • Brief them on UBO Performance (e.g., OHI Capture, Billings & Collections for TPCP, MSA & MAC)

28. Resources • UBO Web Page http://www.tricare.mil/ocfo/mcfs/ubo/index.cfm • UBO Help Desk ubo.helpdesk@altarum.org 703-575-5385

29. Resources (con’t) • CITPO Web Site http://citpo.ha.osd.mil/ Now part of Defense Health Information Management System (DHIMS) • RITPO Web Site https://ritpo.satx.disa.mil/main.asp Now part of Defense Health Services Systems (DHSS)

30. Questions? TMA UBO Deputy Program Manager